International Journal of Stress Management

© 2023 American Psychological Association 2023, Vol. 30, No. 1, 95–107

ISSN: 1072-5245 https://doi.org/10.1037/str0000270

Subjective Workload and the Metabolic Syndrome: An Exploration of the

Mediating Role of Burnout and the Moderating Effect of Physical Activity
Ofer I. Atad1 and Sharon Toker2
1
School of Business, Peres Academic Center
2
Coller School of Management, Tel-Aviv University

In this study, building on Hobfoll’s (1989) conservation of resources theory, we aimed to reveal the effect of
subjective workload at baseline on the likelihood of developing new-onset of metabolic syndrome (MetS), a
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

cluster of cardiovascular risk factors during follow-up. We also aimed to find out whether an increase in job
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burnout mediates this association, and whether the extent of engagement in leisure-time physical activity
(PA) attenuates the effect of workload on MetS. Using a three-wave longitudinal study design, we followed
a sample of 1,966 Israeli employees free of MetS at baseline for 3.5 years on average. We controlled for
multiple confounders, including objective workload (i.e., work hours). Subjective workload at baseline was
associated with the risk of new-onset of MetS, yet this association was moderated by PA. Specifically,
among participants with low PA (37 weekly minutes), a one-point increase in our five-point measure of
subjective workload was associated with a 41% increase in risk of new-onset MetS, whereas among those
with high PA (258 weekly minutes) it was associated with a 38% reduction in risk. Among participants who
engaged in 148 weekly minutes of PA (as recommended by the U.S. Department of Health and Human
Services), an increase in workload did not result in an increased risk of developing MetS. We did not find,
however, any indication for a mediating effect of job burnout. Our findings suggest that engaging in PA
while being overloaded not only protects employees from adverse outcomes but actually reverses the
cardiovascular risk.

Keywords: metabolic syndrome, workload, physical activity, burnout, stress

Almost 25% of organizational health care costs are invested in
activities aimed at preventing cardiovascular diseases (CVD; Goetzel
et al., 2020), which are a leading cause of death throughout the world
(World Health Organization, 2020). A crucial starting point in
preventing CVD is the early detection of clusters of CVD risk factors,
such as the metabolic syndrome (MetS). The Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol
in Adults (2001) defined MetS as the presence of at least three of the
following five factors: (a) abdominal obesity, (b) elevated levels of
triglycerides, (c) low levels of high-density lipoprotein (HDL), (d)
hypertension, and (e) elevated levels of glucose. MetS occurs among
30%−40% of adults in Europe and the United States (Grundy, 2020;
Saklayen, 2018), overlapping with about 20%–30% of the working
population (Schultz & Edington, 2009). Accordingly, substantial
research attention has been devoted to identifying physiological,
psychological, and environmental antecedents of MetS, both in
general (for a review, see Grundy, 2020; Holmes et al., 2010) and
specifically in workplace contexts (e.g., Schultz & Edington, 2009).
This article was published Online First January 2, 2023.
Ofer I. Atad https://orcid.org/0000-0002-5678-4022
This research was supported by grants from the Arie Shirom Foundation
(Grant 01-2015 to Ofer I. Atad) and the Henry Crown Institute, Tel-Aviv
University. The authors would like to thank Itzhak Shapira, Shlomo Berliner,
and Samuel Melamed for their theoretical contribution and financial support
throughout the project.
Correspondence concerning this article should be addressed to Ofer I.
Atad, School of Business, Peres Academic Center, Shimon Peres Street 10,
Rehovot, 7610202, Israel. Email: ofer.atad@gmail.com
Studies addressing MetS in workplace environments have iden-
tified relationships between the incidence of the syndrome and
various indicators of work-related stressors, such as high workload
or high effort and low control or low reward (for a recent review, see
Kuo et al., 2019). Among these indicators, subjective workload has
received the most research attention, as it is one of the more
prominent work-related sources of physiological and psychological
strain (for a review, see Niedhammer et al., 2021). Subjective
workload is broadly defined as employees’ perception that they
are subjected to heavy work demands. “Subjective” workload is
different from “objective” workload in that it does not rely on
quantifying work hours or work tasks but rather on employees’
perceptions that their work demands exceed their abilities or re-
sources to perform these demands.
Though multiple studies have explored the relationship between
subjective workload and MetS (Kuo et al., 2019), the question of
whether subjective workload predicts new-onset of MetS remains
unclear: The research addressing this topic has obtained mixed
results, and the capacity to clearly interpret its findings is further
limited by several confounding factors. In particular, none of the
studies in this vein accounted for the possible effect of objective
workload (working hours), making it impossible to determine the
degree to which perceived workload rather than natural exhaustion
due to long work hours affects new-onset of MetS. Additional
limitations include, for example, the use of dichotomized workload
scores, small samples, unknown status of MetS at baseline, or
cross-sectional designs (limiting the ability to infer causality).
Hence, as concluded by Kuo et al. (2019), additional studies are
needed. The first aim of the current research is to address this need
by identifying whether baseline levels of subjective workload

95
 96 ATAD AND TOKER
predict future onset of MetS over and above work hours and other
possible confounders.
Given that a relationship exists between subjective workload and
new-onset of MetS, the second aim of our study is to explore a
potential mediator for this relationship. Insights gained from this
investigation might make it possible to identify employees who have
been affected by subjective workload but have not yet been diag-
nosed with MetS. In exploring this avenue, we build on the notion of
“spirals of resource loss,” put forward in the conservation of
resources theory (COR; Hobfoll, 1989), in which an initial loss
of time and energetic resources triggers additional loss of resources,
creating a vicious cycle. According to Hobfoll and Shirom (2001), in
workplace contexts, a resource loss spiral, which may be initiated by
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stressors such as subjective workload, can manifest in job burnout—
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conceptualized as physical, cognitive, and emotional exhaustion
(Shirom, 1989). Job burnout, in turn, has been shown to predict
future CVD onset (e.g., Toker et al., 2012) and may suggest that a
deterioration in one’s health status has started taking place. Accord-
ingly, we investigate whether job burnout mediates the relationship
between subjective workload and new-onset of MetS.
Finally, we explore a factor that might moderate this relationship.
Our focus in this investigation is motivated by the fact that, as
reviewed by Goetzel et al. (2020), organizations invest time and
money in programs to promote health, and many of them incorpo-
rate some form of physical activity (PA), as lack of PA has been
associated with the development of MetS (e.g., Pérez-Martínez
et al., 2017; Zhang et al., 2017). We seek to determine whether
employees who experience high subjective workload are likely to
benefit from such initiatives—or in other words, whether leisure-
time PA attenuate the potentially harmful effect of subjective
workload on MetS.
Summing up, we study, for the first time, whether subjective
workload at baseline predicts future onset of MetS, in part through
an increase in job burnout over time, and whether level of engage-
ment in PA moderates this association (see Figure 1). To overcome
empirical limitations of previous studies (cross-sectional designs,
small samples, and specific populations), we carried out a longitu-
dinal study of 1,996 Israeli employees representing diverse indus-
tries and organizations, all free of MetS at baseline. Data were
Figure 1
The Research Model
Note. T = time; H = hypothesis.
collected from each participant at three points in time (T1, T 2, and
T3) over 3.5 years of follow-up on average.
Theoretical Background and Hypothesis Development
Subjective Workload and Metabolic Syndrome
Development
Extensive prior research establishes subjective workload as a
source of physiological and psychological strain (for a review, see
Niedhammer et al., 2021). The physiological effects of work-related
stressors such as workload have been discussed, for example, by
Kuo et al. (2019), who noted that such stressors may repeatedly
activate the sympathetic-adrenal-medullary (SAM) and hypotha-
lamic-pituitary-adrenal (HPA) axes and consequently result in
dysregulation and exhaustion of these vital systems.
To the best of our knowledge, 14 studies to date have investigated
the association between subjective workload and MetS. Nine of
these studies found a positive and significant association (Almadi et
al., 2013; Chandola et al., 2006; Edwards et al., 2012; Garbarino &
Magnavita, 2015; Hwang & Lee, 2014; Loerbroks et al., 2015;
Magnavita & Fileni, 2014; Santos et al., 2018; Schmidt et al., 2015),
whereas five did not (Cho et al., 2006; Demiral et al., 2006; Kang
et al., 2004; Kinnunen et al., 2006; Yamaguchi et al., 2018).
As alluded to above, these studies on the relationship between
subjective workload and MetS had several limitations that may have
prevented them from providing clear conclusions. First, none of the
14 studies accounted for the possible confounding effect of objec-
tive workload (working hours). Accordingly, their results cannot
provide an indication of whether perceived workload has a unique
contribution over and above mere physical exhaustion. Additional
limitations include the use of a dichotomized score of perceived
demands, a procedure with known limitations (MacCallum et al.,
2002). Eight of these studies applied cross-sectional designs
(Almadi et al., 2013; Cho et al., 2006; Demiral et al., 2006;
Hwang & Lee, 2014; Kang et al., 2004; Magnavita & Fileni,
2014; Santos et al., 2018; Schmidt et al., 2015), limiting the ability
to infer causality. For example, employees who are already
experiencing MetS may find it difficult to handle job demands
and consequently perceive them as high. Some studies had an
 SUBJECTIVE WORKLOAD AND THE METABOLIC SYNDROME
unknown baseline level of MetS (Chandola et al., 2006; Kinnunen et
al., 2006) or relied on self-reports of having MetS, as opposed to a
diagnosis reported by physicians (Magnavita & Fileni, 2014).
Additional limitations relate to participants’ characteristics; in par-
ticular, most studies used small samples of specific working popula-
tions, for example, Italian radiologists (Magnavita & Fileni, 2014);
Turkish garbage truck maintenance workers (Demiral et al., 2006);
Italian police officers (Garbarino & Magnavita, 2015); Korean blue-
collar workers (Hwang & Lee, 2014; Kang et al., 2004), or included
only male participants (Almadi et al., 2013; Demiral et al., 2006;
Garbarino & Magnavita, 2015; Kang et al., 2004) or limited age
ranges (Almadi et al., 2013; Edwards et al., 2012; Garbarino &
Magnavita, 2015; Hwang & Lee, 2014; Kinnunen et al., 2006).
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Overall, despite their limitations, the studies presented above
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point to the possibility of a longitudinal effect of high subjective
workload at baseline on new-onset of MetS. However, in order to
reliably establish this relationship, a large and diverse cohort of
employees free of MetS at baseline is needed, using a longitudinal
rather than a cross-sectional design. Moreover, the possible con-
founding effect of objective workload should be considered. For-
mally, we propose the following:
Hypothesis 1: Subjective workload at baseline (T1) predicts
new-onset of MetS at follow-up, over and above the number of
work hours.
Job Burnout as a Possible Mediator of the
Subjective Workload–MetS Association
Employees who experience high subjective workload undergo a
loss of core time and energy resources. This initial resource loss may
further escalate with time, in line with COR theory’s conceptuali-
zation of resource loss spirals, discussed above (Hobfoll, 1989;
Hobfoll & Shirom, 2001).
According to COR theory, as well as other models that address
strain in workplace environments (e.g., job demands-resources;
Demerouti et al., 2001), job burnout is a prevalent manifestation
of such loss spirals. Job burnout is described in the latest version of
the World Health Organization’s International Classification of
Diseases (11th Revision; ICD-11, Code QD85, World Health
Organization, 2019) as a syndrome resulting from chronic work-
place stress that has not been successfully managed. Although there
are various conceptualizations of burnout (Guseva Canu et al.,
2021), “[most] scholars agree that exhaustion is the core constituting
and the necessary component of burnout” (Demerouti et al., 2021,
p. 1). This work-related exhaustion has physical, emotional, and
cognitive manifestations: Physical exhaustion refers to feelings of
fatigue, tiredness, and low levels of energy in carrying out daily
work tasks; emotional exhaustion refers to reduced ability to display
empathy to others; and cognitive exhaustion refers to cognitive
weariness, slow thinking, and reduced mental agility (Hobfoll &
Shirom, 2001).
Reviews of the literature (Alarcon, 2011; Demerouti et al., 2021;
Shoman et al., 2021) suggest that high workload (comprising both
work and time pressure and extended work hours) is indeed a main
source of job burnout, and specifically of its core component of
exhaustion. Moreover, the longer an employee is exposed to high
workload, the higher his/her chances of developing job burnout
(Hallsten, 2017). Hence, in line with previous findings, we expect
97
high subjective workload to result in an increase in job burnout
over time.
Given that burnout is suggested to reflect the occurrence of a
resource loss spiral (Hobfoll & Shirom, 2001), we further propose
that the energetic losses experienced by burnt-out employees may
trigger additional, health-related losses. This proposition is based
on the idea that, from a coping perspective, and as suggested by
Hobfoll and Shirom (2001), low levels of physical energy, cogni-
tive impairments, and cynicism toward others may make it even
harder to meet work demands and consequently intensify the loss
of energetic resources. From a physiological perspective, job
burnout may serve as a warning that a health-related impairment
has already taken place. For example, multiple studies identified an
association between job burnout and dysregulation of the HPA
axis, low cortisol levels (resulting in fatigue), sleep problems, and
inflammation (for a review, see Melamed et al., 2006). Similar
physiological phenomena have been observed in studies focusing
on the role of negative affect—which is closely related to job
burnout—in relationships between stressors and health conse-
quences (for reviews, see Glaser & Kiecolt-Glaser, 2005; Suls
& Bunde, 2005). Notably, whereas affective states and emotions
tend to be transient, job burnout is considered a more chronic
condition, and as such its effect on morbidity is potentially
amplified (Alarcon, 2011).
Considering all the above, we suspect that high subjective
workload may, over time, result in an increase in job burnout,
which, in turn, may result in further health-related resource deple-
tion, including new-onset of MetS. While this mediation proposition
is theoretically supported and has been suggested in an extensive
review of job burnout and cardiovascular risk (Melamed et al.,
2006), we know of no studies to date that have assessed the possible
mediating role of job burnout in the relationship between subjective
workload and new-onset MetS. We do, however, know that job
burnout has been shown to predict new-onset of coronary heart
disease (Toker et al., 2012). As MetS is a risk factor for coronary
heart disease, we expect to find a similar association between job
burnout and MetS. Moreover, some studies have established a link
between job burnout and specific MetS components, such as high
levels of glucose (Grossi et al., 2003; Melamed et al., 1992), low
levels of HDL cholesterol (Wirtz et al., 2003), high levels of
triglycerides (Melamed et al., 1992), and hyperlipidemia (Shirom
et al., 2013). The association between burnout, obesity, and hyper-
tension is less conclusive.
To test whether job burnout mediates a causal association
between subjective workload and MetS, we need a longitudinal
design with at least three measurement waves to allow for both job
burnout and MetS development. Accordingly, the baseline mea-
surement of subjective workload (Time 1; T1) must precede the
measurement of change in job burnout (from T1 to T 2), and the
measurement of the new-onset of MetS (at T3) should then follow.
Formally, we propose the following:
Hypothesis 2: The hypothesized workload–MetS association
is partially mediated by change in job burnout levels, such
that the higher the level of subjective workload at baseline
(T1), the higher the increase in job burnout from T1 to T 2,
and consequently, the higher the likelihood of new-onset of
MetS at T3.
 98 ATAD AND TOKER
Physical Activity as a Possible Moderator of the
Workload–MetS Association
The numerous studies devoted to identifying physiological, psy-
chological, and environmental antecedents of MetS (for a review, see
Grundy, 2020; Holmes et al., 2010) have consistently shown that PA
plays a major role in this syndrome. PA is commonly defined as any
activity that increases the heart rate and brings on a sweat (U.S.
Department of Health & Human Services, 2018). Substantial evi-
dence points to the health benefits derived from PA (Ekelund et al.,
2016; Posadzki et al., 2020). Compared with adults who do not
exercise regularly, adults who routinely engage in PA tend to have
better cardiovascular and respiratory fitness levels, higher health-
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related quality of life, and a lower risk for all-cause mortality
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(Ekelund et al., 2016; Nguyen et al., 2021). Moreover, several
studies, including large-scale meta-analyses (Krishnamoorthy et
al., 2022; Zhang et al., 2017), have explicitly associated PA with
a reduced prevalence of MetS (Esposito & Giugliano, 2014; Frugé et
al., 2015), in part due to the prevention of metabolic alterations
(Pérez-Martínez et al., 2017), and favorable structural changes in the
muscles and in hormone secretion (Saklayen, 2018).
Herein, we argue that routine PA not only directly reduces the risk
of MetS but also interacts with subjective workload in attenuating
the effect of subjective workload on new-onset of MetS. Notably,
research on the role of PA in the relationship between work-related
stress and MetS is still limited (Holmes et al., 2010). We were able to
find only one study that examined whether PA moderates the
relationship between work-related stressors (job content and effort–
reward imbalance) and MetS (Schilling et al., 2020). That study did
not find evidence for such an interaction, yet used a short follow-up
duration of 1 year with only two points of measurement, and thus its
ability to offer evidence for a buffering effect over time was limited.
In addition, the study relied on a small sample (n = 97) of a specific
population (Swiss police officers with high amounts of PA).
Our proposition that the amount of PA may attenuate the
workload–MetS association is grounded in several arguments. First,
drawing from ideas developed in the domain of cognitive behavior
therapy, we suggest that PA may be viewed as a behavioral
distraction that takes people’s minds off work-related stressors
(including workload) and thus reduces the psychological impact
of the situation (Toker & Melamed, 2017). Second, adopting the
perspective of COR theory (Hobfoll, 1989), we suggest that PA can
be seen as a recovery mechanism that halts resource loss spirals
triggered by excessive subjective workload. Specifically, PA allows
employees to temporarily replenish their resources before facing job
demands once again (e.g., Calderwood et al., 2021; Siltaloppi et al.,
2009). Third, to the degree that PA improves personal abilities (e.g.,
McAuley & Blissmer, 2000), it has the potential to reduce sensitivity
to negative stimuli instrumentally. And finally, regular engagement
in PA may elicit physiological changes that enhance employees’
resistance to the harmful consequences of exposure to work-related
stressors (Childs & de Wit, 2014; Fleshner et al., 2011). This
argument has been supported in a review (Huang et al., 2013),
showing that physically fit individuals have attenuated physiologi-
cal reactivity to acute stressors and recover more easily than unfit
individuals.
The physiological rationale underlying the latter findings is based
on the fact that extreme exercising can be a stressor in and of itself. It
activates several systems (i.e., HPA-Axis, sympathetic nervous
system, cardiovascular system; Holmes et al., 2010) and may elicit
a stress response (McEwen, 2007). Over time, as a means of coping
with this stressor, the body undergoes physiological adaptations in
response to repeated bouts of exercise, including a decrease in
resting heart rate and in blood pressure and an increase in parasym-
pathetic activity (e.g., Klaperski, 2018). Similarities between the
central and peripheral physiological responses to exercise and to
psychological stressors have led to the development of the cross-
stressor adaptation theory, stating that physiological adaptations
resulting from regular aerobic PA lead to similar adaptations in
response to psychological stressors (Hull et al., 1984; Salmon, 2001;
Sothmann, 2006). Hence, PA may potentially allow employees to
better regulate their responses to subjective workload, thereby
attenuating the workload–MetS relationship. We note that the extent
to which individuals engage in PA is likely to fluctuate over time;
accordingly, in investigating this proposition, it is preferable to
consider PA longitudinally instead of relying on reports collected at
a single point in time. Formally, we propose the following:
Hypothesis 3: The amount of PA across the study span (T1, T 2,
and T3) moderates the direct effect of subjective workload at
baseline (T1) on the likelihood of new-onset of MetS (T3), such
that the higher the average amount of PA across the study
duration, the weaker the association.
We note that PA may also potentially moderate the workload–
burnout–MetS association, such that the higher the amount of PA,
the weaker the mediation effect. As the theoretical and empirical
rationale for this effect is less straightforward, we will test this
possible moderated mediation path on an exploratory basis.
Method
Data Source and Study Design
We collected all data at one large center for routine health ISRAEL
screenings in Israel, aimed at detecting various diseases (e.g.,
CVD or respiratory diseases), where employees are examined every
18–36 months. The medical examinations include blood sampling,
anthropometric measurements, and physical examinations and are
usually sponsored or subsidized by the employer as a fringe benefit.
Data collection for this study was carried out between 2003 and
2009. Participants completed study questionnaires while awaiting
their turn for the medical examination. The study protocol was
approved by the ethics committees of the medical center as well as
by the university’s institutional review board (IRB) committee (IRB
No. 02-049). All participants signed a written informed consent
form and were able to withdraw their participation from the study at
any time. We assured confidentiality to reduce the risk of social
desirability bias. The response rate across all measurements ranged
from 85% to 91%.
To test the study’s hypotheses, we applied a three-wave longitu-
dinal design targeting a large sample of employees, free of MetS at
baseline that could be followed for several years to detect new cases
of MetS based on clinical data rather than on self-reports. To test the
mediation and moderation hypotheses, we used three points of data
collection (T1, T 2, and T3). The mean time lag from T1 to T 2 was
21.7 months (SD = 10.4), and the mean time lag from T 2 to T3 was
20.6 months (SD = 9.5), representing an average of 3.5 years of
 SUBJECTIVE WORKLOAD AND THE METABOLIC SYNDROME 99

follow-up for a single employee. We measured workload at baseline Final Sample Characteristics
(T1), job burnout at T1 and T 2 (to reflect a change in job burnout, the
mediator), and new cases of MetS, the outcome, at T3, after The final sample’s mean age at baseline was 45.6 years (SD = ÂGE

excluding all employees who had MetS at T1. We also measured
self-reported PA (the proposed moderator) at T1, T 2, and T3 and
used the mean score across the study duration (∼3.5 years) to reflect
a stable measure of this potential moderator.
Participants
Initial Sample
TYPE D'EMPLOI In this study, we define “employees” as those who work for an
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8.5), 32.0% of the participants were women, and participants’ mean GENRE
organizational tenure was 13.2 years (SD = 9.3). Participants
worked on average 48.7 hr a week (SD = 8.4). They had completed
15.9 years of education on average (SD = 2.66) and engaged in an
average of 147.6 min of PA per week (SD = 110.1). Participants
were employed in both private and public sectors, representing both SECTEUR DES
ENTREPRISES
white-collar and blue-collar occupations (35.9% high- and low-
technology companies, 21.1% teaching or academia, 10.0% admin- EMPLOI NON
istration, 6.0% sales and services, 15.0% blue-collar, 2.0% health PRECISE
care, and the rest undefined). Thus, this sample of employees was

employer (not self-employed) and receive a monthly paycheck. Out not restricted to specific sectors or occupations, contributing to the
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of the database consisting of 6,174 employees who visited the
medical center for the first time during 2003–2004, we targeted
2,759 employees (44.7%) who returned for two additional conse-
cutive routine health examinations during the study period, that is,
between 2003 and 2009. These three visits to the medical center
were our data collection points (T1, T 2, and T3, respectively).
Attrition from T1 to T3 resulted from changes in employment status,
fringe benefits, or health care provider. Participants who did not
return for a second or third visit were more likely to be male, older,
and closer to retirement compared with those who returned. We
controlled for these possible confounders in the statistical analyses.
Exclusion Criteria
Among the 2,759 participants in the initial sample, we excluded
793 according to the following criteria. First, as our focus was on
new-onset MetS diagnosis at T3 (i.e., the dependent variable), we
excluded 677 participants who had MetS at T1 to ensure all
participants were free of MetS at baseline. We also excluded
participants who had been diagnosed with cancer, stroke, diabetes,
or CVD at T1. To ensure that our participants represented the
working population, we excluded 69 participants who, at T1,
reported not working or working fewer than 2 hr a day or fewer
than 3 days a week, and 21 participants who retired during the study
period. We also excluded 26 professional athletes (exercising 20–30
hr a week). Hence, the final sample included 1,966 employed adults,
free of MetS at baseline (T1), followed for 3.5 years on average.
study’s external validity (see Table 1, for participant characteristics).
Measures
Metabolic Syndrome
We measured MetS at both T1 and T3. We measured it at T1 for
exclusion purposes, as we targeted a sample of healthy employees at
baseline, and at T3 to identify new cases of MetS during follow-up
(i.e., the dependent variable). We defined MetS according to the
criteria proposed in the Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults (2001). Specifically,
we diagnosed MetS by the presence of three or more of the
following five components: (Component A) central obesity as
measured by waist circumference, greater than 102 cm among
men or greater than 88 cm among women; (Component B) fasting
blood triglycerides greater than or equal to 150 mg/dL; (Component
C) blood HDL cholesterol less than 40 mg/dL among men or less
than 50 mg/dL among women; (Component D) blood pressure
greater than or equal to 130/85 mmHg, or the use of prescribed
medications to lower blood pressure; and (Component E) fasting
glucose greater than or equal to 110 mg/dL. All measurements were
taken and recorded by trained nurses at the medical center. Waist
circumference was measured without clothes. Fasting blood trigly-
cerides and HDL cholesterol were assessed with the Roche/Hitachi
747 Analyzer (Roche Diagnostics, Mannheim, Germany) and the
Raichem Kit (Reagents Applications, San Diego, California, the

Table 1
Descriptive Statistics and Correlations Among Study Variables

Variable M/% SD 1 2 3 4 5 6 7 8 9 10 11

1. Workload (T1) 2.51 0.81 —

2. Burnout (T 2) 1.98 0.77 .27** —
3. MetS (1 = yes, T3) 9.6% .01 −.04 —
4. Amount of PA (mean T1, T 2, T3) 147.6 110.4 −.11** −.13** −.05* —
5. Burnout (T1) 2.12 0.81 .31** .69** −.02 −.12** —
6. Work hours (daily, T1) 9.74 1.68 .26** −.06* .07** −.00 −.07** —
7. Age (T1) 45.63 8.52 −.11** −.09** .07** .10** −.08** −.08** —
8. Gender (women = 1, T1) 32.0% .05* .17** −.11** −.14** .16** −.34** .05* —
9. Education (years, T1) 15.9 2.66 −.00 −.03 −.02 .02 −.06** .11** .07** −.08** —
10. Tenure (years, T1) 13.16 9.28 .04 .03 .03 .02 .05* −.09** .52** .16** −.12** —
11. Smoking (yes = 1, T1) 13.3% .04 .09** .00 −.06** .10** .00 −.04 .07** −.09** .01 —
12. Time gap (months, T1–T3) 42.28 16.87 .03 .01 .00 −.03 .04 −.05* −.12** .11** −.06** .11** .01
Note. N = 1,966, MetS = new-onset of metabolic syndrome; PA = physical activity; SD = standard deviation; T = time.
* p < .05. ** p < .01.
 100 ATAD AND TOKER
United States). Arterial blood pressure (mm Hg) was measured
twice in the left arm while sitting after a 20-min rest while waiting
for the medical examination; the average of two independent
measures was used. Fasting glucose was determined using an
auto-analyzer with the glucose oxidase method (Beckman Instru-
ments, Fullerton, California, the United States). New incidence of
MetS at T3 (three components or more) was coded as “one,” and
nonincidence (zero to two components) was coded as “zero.” Of the
initial sample of employees (all free of MetS at baseline), 188 (9.6%)
were diagnosed with new cases of MetS at T3.
Subjective Workload
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We assessed subjective workload at baseline (T1, the independent
variable) based on each participant’s mean rating of nine items
representing quantitative and qualitative workload, adapted from the
job demand scale of the Job Contents Questionnaire (Karasek &
Theorell, 1990). Sample items were as follows: “I am required to
work too fast” and “I don’t have the sufficient knowledge to carry
out the required tasks.” Responses were anchored on a 5-point
Likert scale, ranging from 1 (to a very little extent) to 5 (to a very
large extent), with Cronbach’s α = 0.88. As detailed below, we
controlled for daily work hours.
Job Burnout
We assessed job burnout at T1 and T 2 (the mediator variable)
using the Shirom–Melamed Burnout Measure (SMBM; Shirom &
Melamed, 2006), which consists of the mean rating of 14 items
representing emotional, physical, and cognitive exhaustion (Cron-
bach’s α = 0.92 for both T1 and T 2). Sample items were as follows:
“I feel physically drained” and “I feel I am not thinking clearly.”
Responses were anchored on a 7-point Likert scale, ranging from 1
(almost never) to 7 (almost always). To reveal the role of change in
T2 burnout as a mediator of the workload–MetS relationship, we
controlled for T1 burnout, such that the analysis captured change in
burnout over time.
Amount of Physical Activity
To measure PA (the moderator variable), in accordance with the
guidelines of the American College of Sports Medicine and the
American Heart Association (Garber et al., 2011; Haskell et al.,
2007), we asked respondents, at T1, T 2, and T3, to report the number
of times in the past week that they had engaged in strenuous PA and
the number of minutes in each session. We specified that participants
should report only PA that they engaged in during leisure time, and
that increased the heart rate and brought on a sweat. The number of
reported minutes of PA was multiplied by the number of reported
weekly times to create a measure of the amount of weekly PA per
visit to the medical center. This self-report measure has been used
extensively (e.g., Miles, 2007; Richardson et al., 2004) and vali-
dated in past studies against objectively measured PA (McMurray
et al., 2004; Pate et al., 2003). To obtain a more reliable and stable
measure of PA across the study duration, we averaged each parti-
cipant’s three measures of weekly PA amount into a single aggre-
gate measure of PA amount, such that the PA score represented the
average amount of PA across 3.5 years.
Control Variables
In our statistical analyses, we controlled for several demographic,
occupational, and health-related variables that have been shown to
contribute to the incidence of MetS. These include baseline levels of
age (e.g., Miranda et al., 2005), gender (e.g., Toker et al., 2008),
years of education (e.g., Wamala et al., 1999), and smoking status
(e.g., Niskanen et al., 2004). Additionally, we controlled for the time
lag, in months, between measurements, as the time gap varied to a
substantial degree across participants. We also controlled for objec-
tive workload, based on the number of daily working hours at T1. In
addition, due to possible cumulative effects of job demands over
time, we controlled for participants’ job tenure at baseline. Finally,
as reported above, we controlled for T1 burnout.
Analytic Strategy
The study hypotheses represent a model encompassing both
moderation and mediation, in which the effect of subjective work-
load at T1 on the onset of MetS at T3 is partially mediated by a
change in job burnout from T1 to T 2 (indirect effect) and is also
moderated by the amount of PA (measured as the average weekly
amount of PA across T1, T 2 and T3; moderation effect). The nature
of our dependent variable (new-onset of MetS at T3, referred to in
what follows, for convenience, as MetS) necessitated a hierarchical
logistic regression. To investigate this model, we applied the
analysis in three steps: First, we examined the main effect of
workload on MetS using a binary logistic regression; next, we
examined the mediation hypothesis based on the procedure sug-
gested by MacKinnon et al. (2007), using the bootstrapping method
(Shrout & Bolger, 2002), with Model 4 of the PROCESS SPSS
macro (Hayes, 2017). Finally, we tested the moderation and media-
tion hypotheses simultaneously using Model 5 of the PROCESS
SPSS macro (Version 4.0), based on a mediator variable (T 2 job
burnout) and a moderator (PA amount) of the workload–MetS
association, with 5,000 bootstrap samples. As recommended by
Aiken and West (1992), to limit the potential for multicollinearity,
we centered the perceived workload variable. For the independent
variables, the variance inflation factors (VIFs) ranged from 1.02 for
the PA intensity variable to 1.98 for T 2 burnout. Thus, all VIFs were
lower than 2.0, indicating that substantial multicollinearity was not
present (Cohen et al., 2003).
Results
Means, standard deviations (SDs), frequencies (where applica-
ble), and Pearson correlations for the variables in this study are
presented in Table 1. The correlations presented in Table 1 indicate
that subjective workload at T1 was positively associated both with
T1 job burnout (r = 0.31, p < .001) and with T 2 job burnout (r =
0.27, p < .001). However, T1 subjective workload was not associ-
ated with new-onset of MetS at T3 (r = .01, p = .609), even though
the number of daily work hours at T1 (i.e., objective workload) was
(r = .07, p = .002). The latter finding highlights the importance of
controlling for work hours in any analysis aiming to investigate
effects of subjective workload. Further, neither T1 burnout nor T 2
burnout was associated with new-onset of MetS (r = −.02, p = .292;
r = −.04, p = .090, respectively). Thus, the bivariate analysis does
 SUBJECTIVE WORKLOAD AND THE METABOLIC SYNDROME
not lend initial support to a direct effect of subjective workload
on MetS.
Testing Hypothesis 1: Main Effect of Subjective
Workload on New-Onset of MetS
We conducted a multivariate binary logistic regression analysis
while controlling for the possible confounding effects of organiza-
tional tenure, daily work hours, age, gender, years of education,
smoking, and the time lag between T1 and T3 (see Table 2, Model 1).
T1 subjective workload was not significantly associated with new-
onset of MetS at T3. The unstandardized β weight for subjective
workload was as follows: B = 0.07, SE = 0.10, Wald = 0.50, p =
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.480. The estimated odds ratio did not support an increase in the
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likelihood of new-onset of MetS, Exp (B) = 1.07, 95% CI [.88,
1.31]; nor did the amount of daily work hours (i.e., an objective
measure of workload), B = 0.09, SE = 0.05, Wald = 3.08, p = .079.
On an exploratory basis, we looked for an interaction of subjective
and objective workload (i.e., Subjective Workload × Work Hours)
yet found no such effect, B = 0.02, SE = 0.05, Wald = 0.20, p =
.653. Hence, Hypothesis 1 was not supported.
Testing Hypothesis 2: Mediating Role of
Changes in Job Burnout
To test whether an increase in job burnout from T1 to T 2 mediates
the association between subjective workload at T1 and new-onset of
MetS at T3, we used the procedures recommended by MacKinnon
et al. (2007). As detailed in Table 2, we tested the hypothesis in an
adjusted model using the PROCESS macro 4 (Version 4.0) for SPSS
software (Version 4.0). As expected, subjective workload at T1 was
associated with an increase in job burnout from T1 to T 2, B = 0.06,
SE = 0.02, p < .001. However, job burnout at T 2 (after controlling
for T1) was not associated with an increased likelihood of develop-
ing MetS at T3 in the adjusted model B = 0.08, SE = 0.11, p = .428.
We repeated this analysis with an unadjusted model, but results
remained consistent. In addition, there was no support for a media-
tion effect, either in the unadjusted model or in the adjusted model
(lower part of Table 2); adjusted indirect effect: B = 0.01, SE = 0.01,
95% CI = [−.03, .01]. Thus, we did not obtain support for
Hypothesis 2.
Testing Hypothesis 3: Moderating Role of Physical
Activity
To test whether PA amount (taken as an average across the three
measurement points) interacts with subjective workload in predict-
ing new-onset of MetS, we used Model 5 of the PROCESS SPSS
macro (Hayes, 2017), which enabled us to test the moderation and
mediation hypotheses simultaneously. Supporting Hypothesis 3,
and after controlling for work hours, T1 subjective workload was
a significant predictor of new-onset of MetS at T3, both in the
unadjusted model, B = 0.42, SE = 0.15, p = .006, and in the adjusted
model, B = 0.46, SE = 0.16, p = .004. To save space, we present
only the adjusted model in Table 2. In addition, the interactive term
of subjective workload and PA was significant in both models
(adjusted model: B = −0.003, SE = 0.01, p = .001). Simple slopes
analysis confirmed the direction of the interaction and revealed
significant effects. Figure 2 illustrates this interaction, adopting a
101
procedure similar to that recommended by Stone and Hollenbeck
(1989), namely, plotting three slopes representing a low amount of
PA (−1 SD = 37.1 weekly minutes), a medium amount (M = 147.6
weekly minutes), and a high amount (+1 SD = 258.0 weekly
minutes). Among employees who engaged in 37.1 weekly minutes,
every increase of 1 point in the subjective workload scale (compris-
ing five anchors) represented an increase of 41% in the likelihood of
developing MetS by T3, B = 0.34, SE = 0.14, p = .012, OR = 1.41,
95% CI [1.08, 1.85]. Among participants who engaged in 147.6
weekly minutes of PA (a level essentially equivalent to the mini-
mum of 150 weekly minutes recommended by the U.S. Department
of Health & Human Services, 2018), an increase in subjective
workload did not result in an increased risk of developing MetS,
B = 0.01, SE = 0.11, p = .928, OR = 1.01, 95% CI [.81, 1.25].
Finally, and somewhat surprisingly, among participants who
engaged in high levels of PA (+1 SD, 258.0 weekly minutes), a
reverse effect was found: An increase of 1 point in the workload
scale represented a decrease of 38% (1/OR = 1/0.72) in the
likelihood of developing MetS, B = −0.32, SE = 0.16, p = .046,
OR = 0.72, 95% CI [.52, .99]. Hence, PA not only attenuated the
effect of subjective workload but was also able to reverse the effect.
Thus, Hypothesis 3 was fully supported.
Exploratory Analysis of a Moderated Mediation
On an exploratory basis, we also looked for a moderated mediated
effect of PA. We examined whether PA amount attenuated the
workload–burnout–MetS association such that the mediation effect
of change in burnout would be weaker for those who engage in a
high amount of PA. We applied, again, the PROCESS SPSS macro
(Hayes, 2017), and specifically Model 59, which included a test of
moderated mediation for the three possible paths. The results
suggested that no such effect exists. While the moderating effect
of PA on the workload–MetS association remained significant ( p =
.002), there was no moderation effect of PA on either workload–T 2-
burnout ( p = .243) or on T 2-burnout–T3-MetS ( p = .902). In
addition, the mediation effect was not moderated by PA. Thus,
change in job burnout did not mediate the subjective workload–
MetS association, regardless of the amount of PA.
Discussion
In light of prior inconclusive findings regarding the relationship
between subjective workload and new-onset of MetS, this study
sought to rigorously test this relationship in a large sample of
employees, taking care to address methodological limitations of
prior works. Moreover, building on COR theory, we sought to
further characterize this relationship by exploring the mediating role
of job burnout and the moderating role of employees’ extent of
engagement in leisure PA. Key strengths of our study include the
implementation of a longitudinal three-wave design, with an aver-
age of 3.5 years of follow-up, an objectively measured health
outcome, a large and diverse sample of employees free of MetS
at baseline, incorporation of a control for objective workload
(number of work hours), and a stable measure of PA (the average
of three measurements). Notably, to the best of our knowledge, our
study is among the first to prospectively examine the role of leisure
PA in the relationship between exposure to work-related stressors
and new-onset of MetS.
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102

Table 2
Logistic Regression of New-Onset of MetS at T3, on T1 Workload, the Mediating Role of Change in Burnout From T1 to T2, and the Moderating Effect of Physical Activity Amount T123

Model 1: main effect Model 2: mediation Model 3: moderation

DV = T3 MetS DV = T 2 Burnout DV = T3 MetS DV = T3 MetS
Variable entered B (SE) Exp(B) B (SE) Exp(B) B (SE) Exp(B) B (SE) Exp(B)

Workload—T1 0.07 (.10) 1.07 0.06 (.02)** 1.07 0.08 (.11) 1.09 0.46 (.16) 1.58**
Job burnout—T2 −0.12 (.15) 0.89 −0.12 (.15) 0.89
Job burnout—T1 0.62 (.02)** 1.87 0.05 (.14) 1.06 0.02 (.14) 1.02
PA—T123 −0.00 (.00) 0.99**
Workload × PA123 −0.00 (.00) 0.99**
Org. tenure—T1 −0.00 (.01) 1.00 0.00 (.00) 1.00 −0.00 (.00) 1.00 −0.00 (.01) 0.99
Work hours—T1 0.09 (.05) 1.09 −0.00 (.00) 0.99 0.09 (.05) 1.09 0.09 (.05) 1.09
Age—T1 .04 (.01)** 1.04 −0.00 (.00) 1.00 0.04 (.01)** 1.04 0.04 (.01) 1.04**
Gender—T1 −0.92 (.22)** 0.40 0.09 (.03)** 1.10 −0.91 (.22)** 0.40 −0.98 (.22) 0.37**
Education—T1 −0.05 (.03) 0.95 0.00 (.00) 1.00 −0.05 (.03) 0.95 −0.06 (.03) 0.94
Smoking—T1 0.09 (.23) 1.09 0.03 (.04) 1.03 0.09 (.23) 1.10 0.06 (.23) 1.06
ATAD AND TOKER

Time lag—T1−3 0.00 (.00) 1.00 −0.00 (.00) 1.00 0.00 (.00) 1.00 0.01 (.01) 1.00
Constant −4.06 (.88)** 0.01 0.640.14)** 1.89 −4.11 (.93)** 0.02 −4.72 (.99) 0.01**
R2 (Nagelkerke) 0.05 0.004 0.02 0.07
Bootstrap mediation analysis
Indirect effect of workload on MetS, B (SE) = 0.01 (0.01) B (SE) = −0.01(.01)
through T 2 burnout 95% CI (−.03, .01) 95% CI (−.03, .01)
Note. N = 1,966. Model 1: main effect model; Model 2: mediation model (adjusted, PROCESS macro, Model 4); Model 3: moderation model (adjusted, PROCESS macro, Model 5). Exp(B) = odds ratio;
MetS = metabolic syndrome; OR = odds ratio; LLCI = lower level confidence interval; ULCI = upper level confidence interval; T1, T 2, T3 = Times 1, 2, 3; physical activity = average weekly minutes of
physical activity across three measurements; Org. = organizational; work hours = average hours of work per week; gender: 0 = men, 1 = women; education = years of education; smoking: 1 = yes; time gap =
number of months between T1 and T3; direct effect = T1 workload > T3 MetS; indirect effect = T1 workload > T1–2 burnout > T3 MetS; Workload was centered to the mean; CI = confidence interval; T = time;
PA = physical activity; SE = standard error; DV = dependent variable.
** p < .01.
 SUBJECTIVE WORKLOAD AND THE METABOLIC SYNDROME 103

Figure 2
Simple Slopes Analysis of the Effect of T1 Subjective Workload on New-Onset of Metabolic Syndrome at T3;
Moderated by Three Levels of Physical Activity (Average of 3 Measurements ± 1SD); Measured During T1, T2,
and T3
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Note. MetS = metabolic syndrome; T = time; CI = confidence interval.

Analyzing data for 1,966 employees who were healthy at base-
line, we did not find a main effect of subjective workload on new-
onset of MetS. Similar null findings were reported in five previous
studies (Cho et al., 2006; Demiral et al., 2006; Kang et al., 2004;
Kinnunen et al., 2006; Yamaguchi et al., 2018). However, we found
that, among those who engaged in low levels of PA (37 weekly
minutes on average), higher levels of subjective workload were
associated with a higher likelihood of developing MetS over the
course of the follow-up period. Among these inactive employees,
every increase of one point in our five-point measure of subjective
workload increased the risk of new-onset of MetS by 41%. Inter-
estingly, we found that engagement in the amount of PA recom-
mended by the U.S. Department of Health and Human Services
(2018, 150 min a week vs. 148 min in our study) completely
attenuated this effect. Moreover, we identified a reverse effect
among those who engaged in high levels of PA (about 260 min
a week). Among these individuals, an increase of one point in the
measure of subjective workload was associated with a reduction of
38% in the likelihood of MetS onset. Together, these findings
suggest that PA may serve as a coping mechanism, one that not
only prevents the so-called resource loss spirals but also may even
help employees acquire new resources, a phenomenon referred to in
COR theory as resource gain spirals (Hobfoll, 1989), and supports
PA’s role in attenuating the effect of stress on CVD risk (Huang
et al., 2013).
Contrary to our theory, we did not find evidence that job burnout
mediates these relationships. We note that the lack of a mediation
effect may have resulted from the fact that burnout levels at T 2 (M =
1.97, SD = 0.77) were actually smaller than burnout levels at T1
(M = 2.12, SD = 0.81). Given that the average organizational tenure
in our sample was 13.2 years, this finding is in line with the
observations of Dunford et al. (2012) that burnout is relatively
stable for organizational insiders. Hence, as burnout tended to
decrease rather than increase during the study, it is possible that
the change in burnout was not significant enough to create the
expected mediation effect, suggesting that study participants did not
experience a spiral of energetic resource loss.
Another possible explanation for the lack of mediation effect is
that the time lag between measurements was not suitable for the
current investigation. Very little is known about the exact time
frame in which a stressor is expected to influence physiological
outcomes. Though researchers have called for more detailed
characterizations of the time frames of stressor–strain relationships
at work (Frese & Zapf, 1988), it is still difficult to plan the correct
time lags for investigations of specific stressors, mediators, and
dependent variables. Although time lags of 8–24 months are
appropriate for investigating stressor–strain relationships
(Dormann & Zapf, 2002), the time lag of 21.7 months between
the two measurements of burnout may have been too long and
obscured the mediation effect.
Notably, our analysis may provide indirect evidence for a mech-
anism that has previously been suggested to underlie the relationship
between work stressors and negative health outcomes (see review by
Kuo et al., 2019): unhealthy behaviors. Specifically, our correla-
tional analysis (Table 1) revealed a significant negative correlation
between subjective workload and PA. Though we did not explicitly
study this relationship, our finding may suggest that employees with
high subjective workload may tend to engage less in PA, which, in
 104 ATAD AND TOKER
turn, increases their risk of MetS, as observed in our moderation
analysis.
Study Limitations
Our analysis did not reveal a main but rather a moderated effect of
subjective workload on the likelihood of developing MetS, in which
only employees who were insufficiently active were affected nega-
tively by high subjective workload. Though this result may indeed
indicate that adequate PA is sufficient to protect against negative
effects of subjective workload, it is important to acknowledge that it
may also be attributable to certain limitations. In particular, we only
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measured workload at baseline and did not assess changes in
This document is copyrighted by the American Psychological Association or one of its allied publishers.
workload over time. It could be that workload changed during
the study period. Additional factors that might explain the null main
effect relate to retention bias within the sample of participants. For
example, we observed that individuals who visited the health center
at T1 and did not return for subsequent visits had higher levels of
burnout and engaged in a lower amount of weekly PA compared
with those who did return. These findings are in line with previous
research suggesting that following the same individuals over an
extended time period might be subject to a “healthy survivor” effect,
as participants with severe illnesses are more likely to drop out of
studies over time (Ferrie et al., 2009). Our participants may also
have been subject to the “healthy volunteer effect” (Froom et al.,
1999); that is, they were likely to have been initially healthier than
individuals who do not participate in routine health examinations.
Indeed, study participants were highly educated and exhibited good
health behavior patterns: they smoked little and exercised regularly,
and this may have resulted in underestimating the true effect of
subjective workload on MetS onset.
We also acknowledge that the effect size (R2) of our moderation
analysis is small. Nevertheless, our findings still suggest that PA
may serve as a crucial means of mitigating the adverse effects that
work-related stressors can have on individuals’ well-being and
health (for a review of these effects, see Ganster & Rosen, 2013;
Harvey et al., 2017). Governments and global health organizations
are constantly searching for ways to minimize these negative effects
and enhance employees’ well-being (Grant, 2017). Considering that
the International Labour Organization (2016) has estimated the cost
of stress at work as up to 3.5% of gross domestic product, and that
the annual cost of workplace stress in the United States is estimated
at $300 billion (American Psychological Association Group on
Stress and Health Disparities, 2017), even a small improvement
could be highly beneficial.
Implications
Our findings have important practical implications for occupa-
tional health policymakers and occupational health organizations
alike. In particular, they suggest that organizations should be
attentive to employees’ subjective workload, as well as to their
extent of engagement in PA, given that a combination of high
subjective workload and insufficient PA is associated with height-
ened risk of developing MetS. Notably, our findings suggest that
engagement in a high frequency of PA has the potential not only to
protect employees from the negative effects of high subjective
workload but even to reverse the effect. In other words, being fit
while having high work demands may simultaneously benefit the
employee’s health and the organization’s bottom line.
Sadly, it is not uncommon for employees faced with strenuous
demands at work to compromise their health—and their engagement
in PA—to prioritize work tasks, and indeed in our study, subjective
workload was negatively correlated with PA. Thus, organizations
should identify interventions that will motivate overwhelmed em-
ployees to exercise more frequently. One option is to encourage
employees to exercise during the workday, as it may provide a
much-needed break and help employees avoid feeling guilty about
taking time away from family to exercise after work. We suggest
that organizations strategically integrate the value of “being fit” into
their culture and effectively communicate this to their employees.
On a practical level, organizations can offer bonuses for engagement
in PA or improvement in fitness level, or even include engagement
in PA as a parameter when evaluating an employee’s candidacy for
promotion.
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Received September 23, 2021
Revision received July 8, 2022
Accepted July 13, 2022 ▪